October 17, 2021

Recognizing and Treating Bacterial Folliculitis

Introduction

Hair follicles are a common place for infection in the training room. Folliculitis is an infection of the hair follicle and is typically found on patients in areas densely populated with hair or in areas where hair removal has just occurred (1).  Folliculitis is seen in all age groups (11). Due to ease of transmission of staph aureus, folliculitis can rapidly spread through a team and within multiple teams in a league (3). Folliculitis differs from a furuncle, which is a localized subcutaneous abscess within the hypodermis, and carbuncles, which are a coalescing of multiple furuncles (5).

Case Introduction

A 16 year old football player has developed a localized rash underlying his thigh pads. On examination the provider visualized multiple pinpoint pustules overlying an erythematous base. No abscess was visualized. Which organism most commonly causes this infection?

A) Staphylococcus aureus
B) Pseudomonas
C) Streptococcus
D) Clostridium

The most common types of folliculitis include staphylococcus and streptococcus folliculitis, pseudofolliculitis barbae, and pseudomonas folliculitis (3). Staphylococcus is the most common bacterial cause of folliculitis and its treatment will be the focus of this review (4). However, providers may also come into contact with hot tub folliculitis, which presents with pruritic papules after exposure to hot tubs or saunas (9).

Illustration of folliculitis

Image 1. Illustration of folliculitis

Diagnosis

Diagnosis of folliculitis is typically a clinical diagnosis. Inflammation of the hair follicle typically presents as a small pustule with an erythematous base (3). These lesions will usually look “pimplelike” due to the inflammation of the hair follicle (9). Patients can complain that lesions are either pruritic or mildly painful pustules under their pads (3). Culture of any drainage can identify the responsible agent (9).

Clinical example of folliculitis
Image 2. Clinical example of folliculitis

Treatment

For cases of uncomplicated folliculitis, removal of the causative agent is first line (11). Topical chlorhexidine gluconate 2% to 4% solution wash should be used to cleanse the area (10). Warm compresses can also be used to help promote spontaneous drainage (2). More resistant lesions are treated with topical mupirocin (2). Mupirocin has good activity against staph aureus (2). Mupirocin has limited systemic absorption and is typically prescribed as a 2% ointment (7). However, with more frequent use there have been increasing levels of resistance seen in MRSA isolates (7).

For severe cases or those who fail first line measures, oral antibiotic coverage should be used (11). Antibiotic coverage should be determined by local bacterial resistance (11). The most commonly used agents include cephalexin for MSSA coverage (3) and doxycycline or trimethoprim-sulfamethoxazole if MRSA is suspected (3).

The guidelines for return to play following bacterial folliculitis are based off of the recommendations provided by the National Collegiate Athletic Association for return to wrestling. The guidelines state that patients should not return to play until they have no new lesions for 48 hours and have completed 72 hours of antibiotic treatment (3). They should have no new lesions at the time of the game or practice (3).

Conclusion

Folliculitis is commonly seen in the athletic training room. Due to its rapid spread, providers must follow national guidelines to avoid spread to other team and players.

By: Gregory Rubin, DO
Rubinsportsmed.com

Case Conclusion

Answer: A, staphyloccus aureus. The patient in the vignette has bacterial folliculitis which is a
superficial infection of the hair follicle. Clinical presentation is a pustule with an erythematous base. Treatment includes topical mupirocin or oral Cephalexin for MSSA coverage.

Carr, Patrick C., and Thomas G. Cropley. “Sports Dermatology: Skin Disease in Athletes.” Clinics in Sports Medicine, vol. 38, no. 4, Oct. 2019, pp. 597–618. PubMed,

References

  1. 1)      Preda-Naumescu, Ana, et al. “Common Cutaneous Infections: Patient Presentation, Clinical Course, and Treatment Options.” The Medical Clinics of North America, vol. 105, no. 4, July 2021, pp. 783–97. PubMed, https://doi.org/10.1016/j.mcna.2021.04.012.

2)      Mistry, Rakesh D. “Skin and Soft Tissue Infections.” Pediatric Clinics of North America, vol. 60, no. 5, Oct. 2013, pp. 1063–82. PubMed, https://doi.org/10.1016/j.pcl.2013.06.011.

3)      Sedgwick, Peter E., et al. “Bacterial Dermatoses in Sports.” Clinics in Sports Medicine, vol. 26, no. 3, July 2007, pp. 383–96. PubMed, https://doi.org/10.1016/j.csm.2007.04.008.

4)      Carr, Patrick C., and Thomas G. Cropley. “Sports Dermatology: Skin Disease in Athletes.” Clinics in Sports Medicine, vol. 38, no. 4, Oct. 2019, pp. 597–618. PubMed, https://doi.org/10.1016/j.csm.2019.06.001.

5)      Breyre, Amelia, and Bradley W. Frazee. “Skin and Soft Tissue Infections in the Emergency Department.” Emergency Medicine Clinics of North America, vol. 36, no. 4, Nov. 2018, pp. 723–50. PubMed, https://doi.org/10.1016/j.emc.2018.06.005.

6)      Gold, Howard S., and Satish K. Pillai. “Antistaphylococcal Agents.” Infectious Disease Clinics of North America, vol. 23, no. 1, Mar. 2009, pp. 99–131. PubMed, https://doi.org/10.1016/j.idc.2008.10.008.

7)      Lio, Peter A., and Elaine T. Kaye. “Topical Antibacterial Agents.” Infectious Disease Clinics of North America, vol. 23, no. 4, Dec. 2009, pp. 945–63, ix. PubMed, https://doi.org/10.1016/j.idc.2009.06.006.

8)      Hatlen, Timothy J., and Loren G. Miller. “Staphylococcal Skin and Soft Tissue Infections.” Infectious Disease Clinics of North America, vol. 35, no. 1, Mar. 2021, pp. 81–105. PubMed, https://doi.org/10.1016/j.idc.2020.10.003.

9)      Watkins, Richard R., and Michael Z. David. “Approach to the Patient with a Skin and Soft Tissue Infection.” Infectious Disease Clinics of North America, vol. 35, no. 1, Mar. 2021, pp. 1–48. PubMed, https://doi.org/10.1016/j.idc.2020.10.011.

10)   Miller , Mark, and Stephen Thompson. DELEE, DREZ, & MILLER’S ORTHOPAEDIC SPORTS MEDICINE, FIFTH EDITION. Elsevier.

11) Sladden, Michael J., and Graham A. Johnston. “More Common Skin Infections in Children.” BMJ, vol. 330, no. 7501, May 2005, pp. 1194–98. DOI.org (Crossref), https://doi.org/10.1136/bmj.330.7501.1194.

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